SPOKANE COUNTY FIRE DISTRICT NO. 12
_____ Firefighter _____ EMS
NAME:_______________________________________________________________________ ADDRESS:____________________________________________________________________ HOW LONG AT THIS ADDRESS:_______ TELEPHONE:__________________________ PERSONAL HISTORY DATE OF BIRTH:_________ AGE:_____ MARITAL STATUS: ____SINGLE ____MARRIED NAME OF SPOUSE:_____________________________________________________________ HEIGHT:_______ WEIGHT:_________ HAIR COLOR:___________ EYE COLOR:_______ SOCIAL SECURITY NUMBER:_______________________________ WASHINGTON STATE DRIVERS LICENSE #:______________________________________ RESTRICTIONS OR ENDORSEMENTS ON WSDL:__________________________________ TRAFFIC CITATIONS INLAST THREE YEARS:_____________________________________ FELONY CONVICTIONS:________________________________________________________ MEDICAL AND EMERGENCY: IN CASE OF EMERGENCY NOTIFY:______________________________________________ RELATIONSHIP:______________________ ADDRESS/PHONE:________________________ PHYSICIAN:_____________________________________ PHONE:______________________ BLOOD TYPE:_______________ ALLERGIES:______________________________________ PHYSICAL RESTRICTIONS, DISABILITIES, OR LIMITATIONS (INCLUDE VISION, HEARING, BACK PROBLEMS, LIFTING ABILITY, FEAR OF HEIGHTS, ETC.)_____________________________________________________________________________
EDUCATION: HIGH SCHOOL GRADUATE: ___ YES ___ NO ___ GED COLLEGE (MARK HIGHEST YEAR COMPLETED): __0 __1 __2 __3 __4 __5 __6+ DEGREE __NONE __AA/AS __BA/BS __MASTER __OTHER (SPECIFY)________________ MAJOR AREAS OF STUDY______________________________________________________
EMPLOYMENT HISTORY: PRESENT EMPLOYER:__________________________________________________________ ADDRESS:_________________________________________ PHONE:____________________ OCCUPATION:______________________________________ SHIFT:____________________ EMPLOYMENT DATE:_____________________________________ PREVIOUS EMPLOYER:________________________________________________________ ADDRESS:_________________________________________ PHONE____________________ OCCUPATION:____________________ EMPLOYMENT DATES:_______________________
FIREFIGHTER HISTORY: Training:_____ None _____ Washington State Fundamentals of Firefighting Other training (include dates, locations and certificates):_________________________________ ______________________________________________________________________________ Experience: ____ None ____ Structural _____ Forest _____ Field _____other: list dates and locations:______________________________________________________________________ FIRST AID – EMS HISTORY: Training:_____ None _____ Prior training – level:_____________ date expired:______________ PRESENT QUALIFICATIONS: _____basic first aid _____advanced first aid _____first responder – expires:_____________ _____ EMT – state:________ expires:________ _____IV tech _____ Airway tech _____Defib _____Paramedic – state: _____ expires:_____ _____RN _____ LPN ____________ other
EXPERIENCE:_____ none _____ field EMS (fire or ambulance) _____ ER _____ other, give date and location ________________________________________________________________
REFERENCES: (no relatives) list name, address, telephone number 1. ____________________________________________________________________________ 2. ____________________________________________________________________________ 3. ____________________________________________________________________________
CERTIFICATION: I hereby certify that the answers given in this application are true and correct to the best of my knowledge. Signature____________________________________________ Date:____________ Acceptance by District: ___________ accepted __________ not accepted Fire Chief:_____________________________________________________ Date:___________
MEDICAL EXAMINATION QUESTIONEER
Are you in good health__________ do you have or previously had any disabilities whereby you full physical capacities are limited yes:_____ no:_____ if so explain:______________________ ______________________________________________________________________________
Have you ever had any of the following diseases or conditions: (if so please explain) Heart trouble:____________________________________________________________ Kidney or Urinary trouble:__________________________________________________ Tuberculosis or lung disease:________________________________________________ Stomach ulcers/gastrointestinal disease:________________________________________ Diabetes:________________________________________________________________ Epilepsy:________________________________________________________________ Mental disease:___________________________________________________________ Nervous system problems:__________________________________________________ Rheumatism/arthritis:______________________________________________________ Back problems:___________________________________________________________ Allergies (ie: asthma, hay fever, eczema):______________________________________ Vision defects:___________________________________________________________ Hearing defects:__________________________________________________________ Hernias:________________________________________________________________
What serious illnesses, accidents, injuries or operations have you had?______________________ ______________________________________________________________________________
List any government, insurance compensations or disability awards you have received. What for?______________________________________________________________________ ______________________________________________________________________________
(I hereby certify that the above answers are full, complete and true to the best of my knowledge.)
Volunteer’s signature:______________________________________ Date:_________________
SPOKANE COUNTY FIRE DISTRICT NO. 12
PHYSICAL EXAMINATION
APPOINTMENT TIME AND DATE:_______________________________________________ TO BE FILLED OUT BY PHYSICIAN: HEIGHT:_________ WEIGHT:_________ PULSE:_________ BLOOD PRESSURE:_________ GENERAL APPEARANCE:_______________________________________________________ VISION: UNCORRECTED: R_______ L_______ CORRECTED: R_______ L_______ NECK:________________________________________________________________________ LUNGS:_______________________________________________________________________ HEART:_______________________________________________________________________ ABDOMEN:___________________________________________________________________ INGUINAL REGION:____________________________________________________________ SPINE:________________________________________________________________________ EXTREMITIES: LIMITED MOTION OR IMPAIRED FUNCTION, DEFORMITIES:________ ______________________________________________________________________________ NERVOUS SYSTEM: PUPILS:____________ KNEE JERKS:_____________ ROMBERG____________ TREMORS______________ GAIT_____________
PHYSICIAN’S OPINION: CAPABLE OF SUSTAINED ARDUOUS DUTY:_______________________________ CAPABLE OF MODIFIED DUTY:__________________________________________ LIMITATIONS:__________________________________________________________
_______________________________________ __________________ PHYSICIAN’S SIGNATURE DATE
____________________________________________ VOLUNTEER’S SIGNATURE
____________________________________________ SIGNATURE OF FIRE CHIEF OR EMS DIRECTOR
SPOKANE COUNTY FIRE DISTRICT NO. 12 FIRE DISTRICT POLICY
REQUIREMENTS FOR PHYSICAL EXAM BY PHYSICIAN DATE:_______________
If a physical examination is required, the Fire Chief and/or EMS Director will inform the District Secretary who will then fill in the Procedure form, make the appointment with the Medical Director at which time the volunteer will take the form back to either the Fire Chief or the Ambulance Director before said appointment and have it signed. At the time of the appointment, the volunteer will have the Medical Director sign and return the form to the secretary.
COMMISSIONERS:
Jim Carlson Dave Krell Tom Pottratz
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